Pressure ulcer staging

The National Pressure Ulcer Advisory Panel (NPUAP) staging criteria will be used to stage all HAPUs [11]. Staging will be completed by an expert RN blinded to the patients’ study allocation. Adjudication will occur with the study team for any wounds that are difficult to stage.

Stage I, non-blanchable erythema: intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. This stage may indicate “at risk” persons

Stage II, partial thickness skin loss: partial-thickness loss of dermis presenting as a shallow, open ulcer with a red-pink wound bed, without slough. This may also present as an intact or open/ruptured serum-filled or sero-sanginous-filled blister. It presents as a shiny or dry, shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration or excoriation. *Bruising indicates deep tissue injury

Stage III, full-thickness skin loss: full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. This may include undermining and tunneling. The depth of a category/stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleoli have no (adipose) subcutaneous tissue and category/stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep category/stage III pressure ulcers. Bone/tendon is not visible or directly palpable

Stage IV, full-thickness tissue loss: full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. This stage often includes undermining and tunneling. The depth of a category/stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleoli have no (adipose) subcutaneous tissue and these ulcers can be shallow. Category/stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable